Mario Cesar Vidal

Normal people working in normal organizations with normal equipment: System safety and cognition in a mid-air collision

A fundamental challenge in improving the safety of complex systems is to understand how accidents emerge in normal working situations, with equipment functioning normally in normally structured organizations. We present a field study of the en route mid-air collision between a commercial carrier and an executive jet, in the clear afternoon Amazon sky in which 154 people lost their lives, that illustrates one response to this challenge. Our focus was on how and why the several safety barriers of a well structured air traffic system melted down enabling the occurrence of this tragedy, without any catastrophic component failure, and in a situation where everything was functioning normally. We identify strong consistencies and feedbacks regarding factors of system day-to-day functioning that made monitoring and awareness difficult, and the cognitive strategies that operators have developed to deal with overall system behavior. These findings emphasize the active problem-solving behavior needed in air traffic control work, and highlight how the day-to-day functioning of the system can jeopardize such behavior. An immediate consequence is that safety managers and engineers should review their traditional safety approach and accident models based on equipment failure probability, linear combinations of failures, rules and procedures, and human errors, to deal with complex patterns of coincidence possibilities, unexpected links, resonance among system functions and activities, and system cognition.

Designing for patient risk assessment in primary health care: a case study for ergonomic work analysis

In this paper, we study the importance of a consistent description of real work in patient risk assessment in the primary healthcare domain. Through a case study in the context of primary health care, we address the research problem of finding ways to build consistent real work descriptions of the patient risk assessment system in the primary healthcare domain, in order to foster the design of improved work situations and support devices. This is a qualitative field study based on ethnographic observation and semi-structured interviews carried out among professionals involved in the risk assessment process in a primary healthcare facility. The objects of ergonomic work analysis were work places and work situations with focus on human activity, as well as surrounding aspects. The analysis identified elements in the work domain with high cognitive demand and operations that could increase mental workload, providing elements for the earlier stages of the design of work situations and support devices to improve the risk assessment in primary health care. This paper shows the usefulness of real work descriptions in the design for complex situations like the risk assessment in health care, as well the impact of poor descriptions in generating harmful situations for both the patient and healthcare practitioners in the explored domain.

Ergonomic sustainability based on the ergonomic maturity level measurement

This paper aims at the application of an ergonomic maturity model (EMM), in order to assess the ergonomic sustainability outreach of ergonomic actions. This proposition was motivated by the widespread sensation that the development of the discipline, its educational devices and related practices depends on the attitude of ergonomics practitioners rather than environmental macroergonomic conditions. Maturity modeling in this paper is undertaken as a tool for ergonomic practitioners. Thus, its foundations were uprooted from diverse fields: Clinic Psychology, Quality Management and Project Management. The paper brings about a detailled explanation of this ergonomic maturity tool. The empirical part is fulfilled by the examination - using the EMM - of four emblematic cases excerpted from our research lab ergonomic portfolio.

Uma abordagem adaptativa de intervenção para mudança organizacional

Growing globalization of the world economy requires a need from organizations to become competitive, in a sustainable way, leading them to implement organizational management change programs aiming at continuous performance improvement. Experiences of several organizations have demonstrated that the achievement of effective changes in organizations depends, fundamentally, on the type of intervention used to implement the change program. This article introduces an adaptive facilitated-change intervention approach, based on the application of the complex adaptive systems theory to the organizations developed using a case study related to a change program of a Brazilian research and development public organization of the nuclear field. The results related to the progress of the organizational level of excellence achieved between 2000 and 2003 enables one to conclude that the developed adaptive intervention provides a certain degree of governance to the changing process, facilitating an effective implementation of a management system based on the Model of Excellence of the Brazilian Quality Award.

A method to assess safety and resilience in radiopharmaceuticals production process

Radiopharmaceuticals are radiation-emitting substances used in medicine for radiotherapy and imaging diagnosis. A Research Institute, located in Rio de Janeiro, produces three radiopharmaceuticals: the sodium iodate is used in the diagnosis of thyroid dysfunctions, the meta-iodo-benzylguanidine is used in the diagnosis of cardiac diseases, and the fluordesoxyglucose is used in diagnosis in cardiology, oncology, neurology and neuropsychiatry. This paper presents a method to access safety and resilience in radiopharmaceuticals production processes. The method uses resilience indicators in order to proactively evaluate and manage the safety.

Análise de microincidentes na operação de usinas nucleares: estudo de caso sobre o uso de procedimentos em organizações que lidam com tecnologias perigosas

Organizations that work with hazardous materials, such as nuclear power plants, offshore installations, and chemical and petrochemical plants, have risk management systems involving accident control and mitigation to ensure the safety of their facilities. These systems are based on physical devices, such as protective barriers, equipment and systems aimed at preventing the occurrence and propagation of accidents, and on human aspects such as regulations and procedures. This paper analyzes the use of a variety of procedures by nuclear power plant control room operators. The methodology consisted of analyzing the work of control room operators during the normal operations, shutdown, and startup of a nuclear power plant, and in full scale simulator training. This survey revealed that routine noncompliance to procedures was considered normal according to the operating rationale, which is based on technical, organizational and cultural factors. These findings indicate that the competencies nuclear power plant operators must possess far exceed proper technical training and the ability to follow written instructions.

A necessidade de novos métodos para análise de acidentes de trabalho na perícia judicial

Our goal is to demonstrate the need to change the work accident analysis methods in judicial expertise. We propose abandoning the easy model of unsafe acts committed by an employee, which has been used to blame the workers and not to avoid new accidents. The method we propose starts with a comprehensive and careful analysis of the activity undertaken and the socio-cultural environment where the event occurred. Ergonomic work analysis is used to understand the actual work situation. This article uses a real case to show how an expert, based on the proposed method, argued the case in the Labor Court.

Conceptual design pattern for ergonomic workplaces.

In this paper, we analyzed two laboratories of liquid chromatography (LC), separation technique of mixtures and identification of its components, in order to identify projectual gaps relating to the environment and the working station. The methodology used was the ergonomic analysis with interactional and participatory techniques applied during the activity performance. This work incorporated and adapted the concept developed by Alexander (1979)--pattern languages--passing from architectural projects to workstations project and physical arrangement of the work environment. The adaptation of the concept resulted in a list of recommendations, requirements and concepts that have brought design solutions for the problematic aspects observed in the ergonomic analysis. The employed methodology, strongly supported in ergonomics principles, and in interactional and participatory techniques, contributed to achieve our gold that is what we now call Conceptual Standards. The patterns go beyond of a usual model of book a of ergonomics specification, once incorporating the viewpoint of the end user, it is also a set of best project practices and of project management in conception ergonomics.

Accounting Standard for Ergonomics: Relation of Ergonomics and Accounting

The presentation of costs in ergonomics has been studied for some years, and has been increasingly used by professionals in the field. These costs, whether regarding the lack of ergonomics or regarding the ergonomic intervention can generate equity variations in the companies, which must be demonstrated in a reliable way to the stakeholders. This paper aims to demonstrate that the ergonomic intervention causes changes in the equity of the companies and, therefore, should present a unique accounting standardization. This paper presents a case in the food industry, more specifically a pasta production plant that outputs several pasta products. After the ergonomic intervention, the company presented accounting values that did not represent the reality of the company, indicating a variation of 5% when they should present a variation of less than 1%. The value of the company’s assets would be lower, so that the expenses would be overestimated in the first year, presenting a lower profit than the real, presenting a profit lower than the real in the first period, and above the real in later periods. Incorrect disclosure of these variations may cause problems for investors who will not have access to the information needed to make the best decision.

The Need to Present Actual Costs After an Ergonomic Intervention

The importance of costs in Ergonomics has been demonstrated through several studies over the last years. Generally the studies tend to be biased to financially justify the ergonomic intervention, using estimated initial data. This paper aims to demonstrate that there is a need for a new cost verification at the end of the intervention, in order to present the actual values to the top management of the company, making the technical report more complete and useful to the several company’s departments, and specifically the accounting and financial ones. The applied methodology was adapted from Lahiri et al. (2005) and Mafra (2004) in a case study in the food industry. The estimate presented by the team at the beginning of the work was R